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Surgical helmet systems (SHSs) have been used to decrease iatrogenic contamination to prevent periprosthetic joint infections. However, the use of SHSs has been controversial. Therefore, the purpose of this study was to investigate iatrogenic contamination of traditional surgical attire (TSA), SHSs, and SHSs with delayed ventilation (SHS-DV) (helmet fan not turned on until surgeon gowned and gloved). A total of 180 orthopedic surgical procedures were prospectively enrolled and randomized into one of three cohorts. The TSA cohort included any orthopedic procedures, while the SHS and SHS-DV cohorts included arthroplasty procedures. Cultures were obtained from bilateral forearms, axillae, the sternum, and face shields for SHS groups. There were 60 surgeries in each group. The rate of positive cultures was calculated for each cohort and stratified by location and type of microorganism. The positive culture rates were 15% in the TSA, 25% in the SHS, 18% in the SHS-DV cohorts. The positive swab culture rates were 6% in the TSA, 7% in the SHS, and 4% in the SHS-DV cohorts. The positive culture rate was highest from the forearms in the TSA cohort (10%), the face shield in the SHS cohort (20%), and the chest in the SHS-DV cohort (7%). Coagulase-negative Staphylococcus was the most common bacteria cultured. The overall bacterial contamination rates were similar between the TSA and the SHS cohorts, with a lower rate in the SHS-DV cohort. Waiting to initiate airflow in SHSs and treating the shields as contaminated may reduce iatrogenic contamination. [ Orthopedics . 2021;44(6):e753–e756.]

Understanding trends in reimbursement is critical to the financial sustainability of orthopedic practices. Little research has examined physician fee trends over time for orthopedic procedures. This study evaluated trends in Medicare reimbursements for orthopedic surgical procedures. The Medicare Physician Fee Schedule was examined for Current Procedural Terminology code values for the most common orthopedic and nonorthopedic procedures between 2000 and 2016. Prices were adjusted for inflation to 2016-dollar values. To assess mean growth rate for each procedure and subspecialty, compound annual growth rates were calculated. Year-to-year dollar amount changes were calculated for each procedure and subspecialty. Reimbursement trends for individual procedures and across subspecialties were compared. Between 2000 and 2016, annual reimbursements decreased for all orthopedic procedures examined except removal of orthopedic implant. The orthopedic procedures with the greatest mean annual decreases in reimbursement were shoulder arthroscopy/decompression, total knee replacement, and total hip replacement. The orthopedic procedures with the least annual reimbursement decreases were carpal tunnel release and repair of ankle fracture. Rate of Medicare procedure reimbursement change varied between subspecialties. Trauma had the smallest decrease in annual change compared with spine, sports, and hand. Annual reimbursement decreased at a significantly greater rate for adult reconstruction procedures than for any of the other subspecialties. These findings indicate that reimbursement for procedures has steadily decreased, with the most rapid decrease seen in adult reconstruction. [ Orthopedics. 2018; 41(2):95–102.]

Perioperative pain management should now be an integral part of all inpatient and outpatient orthopedic surgical procedures. In addition to planning the surgical approach, equipment, and implants needed for a successful surgical outcome, the orthopedic surgeon should also be involved with and help plan the perioperative pain management strategies. Patient outcome and satisfaction data, especially pain relief after surgical procedures, will soon be required to be reported to the Centers for Medicare and Medicaid Services (CMS) using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores,1 and lower scores may eventually negatively affect hospital reimbursement. This special supplement to ORTHOPEDICS is focused on newer aspects of perioperative pain management. Multimodal pain protocols are now considered “state of the art” for all surgical procedures. The fi rst article reviews the general concepts of multimodal pain management, with a major goal being the reduction in the amount of opioid medications required for the postoperative orthopedic patient. This goal should be carefully considered, as The Joint Commission recently issued a Sentinel Event Alert on the safe use of opioids to reduce adverse events in hospital settings.2 The alert included suggestions for actions regarding hospital processes, technology, education, and standardized tools that can be used to screen patients for risk factors associated with oversedation and respiratory depression. This alert also recommended the use of modalities, nonopioid medication, and nerve blocks to decrease the incidence of opioid-related adverse reactions. The second article of this supplement introduces the use of intravenous acetaminophen for perioperative pain protocols for a wide variety of orthopedic procedures. Although this medication has been routinely used for almost 10 years in Great Britain, it has only been available for use in the United States since January 2011. Many orthopedic surgeons may not be familiar with the mechanism of action and the unique pharmacokinetics of this medication when given intravenously. There are major differences in serum and cerebrospinal fl uid levels when this medication is given orally and intravenously. The third article, from Great Britain, is a prospective cohort study of the use of intravenous paracetamol (acetaminophen) preoperatively in a group of elderly patients with hip fractures. These elderly patients with multiple comorbidities seem to be an ideal group to be given nonopioid medications both preand postoperatively. The fourth article is a retrospective cohort study of one hospital’s multimodal pain management protocol in total hip and knee arthroplasty patients, specifi cally looking at the preoperative use of two intravenous medications to decrease the amount of opioid medication used postoperatively. Pain management seems particularly crucial after total knee arthroplasty, because late residual unexplained pain may be related to less than optimal postoperative pain management. Obviously, there are many multimodal pain strategies that may be employed for these patients. The fi nal paper describes one hospital’s postoperative multimodal pain protocol following adolescent scoliosis surgery, in which rapid recovery of gastrointestinal function and avoidance of ileus is important for rapid overall recovery. The orthopedic surgical team should consider a reevaluation of their present pain management protocols to increase patient satisfaction and decrease the amount of opioid medication given perioperatively.

American hospitals face increasing constraints due to a variety of factors. Federal and state diagnostic-related group (DRG) prospective hospital pricing has caused tremendous fiscal pressure on hospitals; many face substantial financial deficits. We analyzed the volume of orthopedic surgical procedures performed by an individual orthopedic surgeon for all patients (N = 2, 134) treated for a 3-year period at a large academic medical center; these surgeons were arbitrarily divided into low volume or high volume. Patients of low volume surgeons had a longer hospital length of stay and hospital cost (after correction for DRG case mix and severity of illness), greater financial risk under DRGs, and a poorer outcome, compared with patients of higher volume orthopedic surgeons. Pearson correlation showed an inverse relationship between cost per patient and physician volume for nonemergency patients -0.201 (P

With pharmacological treatment, the lifespan of the patient with sickle cell disease can be extended to the sixth decade. Currently the only curative therapy for sickle cell disease is hemopoietic cell transplantation, which is still undergoing technical refinement. Most patients can be expected to undergo at least one orthopedic surgical procedure in their lifetime. Multidisciplinary management of orthopedic patients with sickle cell disease will decrease the overall complication rates and improve clinical outcomes.

Between January 1, 1989 and July 31 , 1995, voluntary preoperative screening tests for human immunodeficiency virus (HIV) infection, using an enzyme-linked immunosorbant assay, were completed on 2727 patients who underwent elective orthopedic surgical procedures. There were 2719 (99.7%) negative, 4 (0.15%) positive, and 3 (0.11%) false-positive results; 1 test was indeterminate (0.04%). All 4 positive patients were men with a mean age of 32 years (range: 26-43 years). Although the prevalence of positive tests is low in this setting, voluntary testing alerts the surgeon to higher risk patients, does not sacrifice patient care, and enables the incorporation of more extensive precautionary measures in the operating room to minimize occupational risks to the surgical team.

An open, nonrandomized study of 25 patients was conducted to evaluate the efficacy of cefoxitin in the prevention of postoperative infection following orthopedic surgical procedures. Cefoxitin was administered in a 2 g dose preoperatively and continued postoperatively at a dose of 2 g every six hours for 72 hours. The mean peak serum level achieved ten minutes after the preoperative dose was 153.7 mcg/ml. The mean bone level in samples taken during the procedure was 10.14 mcg/ml. All patients were monitored postoperatively and at intervals of six weeks, four months and six months for signs of early or late morbidity. No signs of major morbidity were observed in the study group. Indexing terms: cefoxitin; prophylactic antibiotics; arthroplasty; kinetics, bone penetration.